Talking With Patients About Recurrence Risk in Ovarian Cancer

Angeles Alvarez Secord, MD: Michelle, you did great for a while. Things were looking really wonderful. I saw you for a few surveillance visits, and I felt like you were getting your energy back, which was good. Then a year later, it’s 2015, and you had a documented recurrence based on imaging, and your CA-125 started to creep up. At that point, we had a conversation about what the next steps are. But I think we had also discussed before, when you completed treatment, the high recurrence risk. Patients with ovarian cancer, their relapse rate is about 70%.

Michelle Berke: That’s pretty high.

Angeles Alvarez Secord, MD: And I always have a hard time, at the end of treatment that first time, having that discussion because you want to be really honest about the high relapse rate, but you also want to instill hope…

Michelle Berke: And encouragement.

Angeles Alvarez Secord, MD: Right. How did you feel at that moment?

Michelle Berke: Devastating. It’s devastating when you hear that your cancer is back. But there’s no cure for it, so it’s to be suspected. So soon? No, I wasn’t expecting it to come back so soon.

Michelle Berke: Yes. You explained that to me how when you have the BRCA1-positive protein, it actually helps your cancer.

Angeles Alvarez Secord, MD: It does help your cancer. And it doesn’t make sense. That’s the huge paradox, right?

Michelle Berke: Yes.

Angeles Alvarez Secord, MD: It increases the risk of someone having cancer, but at the same time, it makes the cancer more susceptible to the chemotherapy, and that goes into the science about what BRCA1 and BRCA2 proteins do. They’re involved in DNA repair. They’re involved in a specific type of DNA repair that’s the most efficient one. And there are all these different pathways to repair DNA.

Michelle Berke: Fascinating.

Angeles Alvarez Secord, MD: Yes, it is very fascinating. But on the whole, it totally makes sense that it doesn’t make sense.

Michelle Berke: To you, it makes sense. To me, it doesn’t make sense. But I trust you anyway, so I’ll trust you on that.

Angeles Alvarez Secord, MD: Right. It’s a really weird phenomenon. So, at the time that you had recurrence, we talked about different treatment options then. I don’t know if you remember.

Michelle Berke: I do. There were a couple clinical trials.

Angeles Alvarez Secord, MD: We’re really fortunate at our practice that we have so many clinical trials that we can offer patients. In your situation, we chose to do the treatment off of a clinical trial, and we talked about different chemotherapy options and adding back in the bevacizumab.

At that point, there had been some information about bevacizumab improving disease control if you added it back with the chemotherapy. You did what’s called maintenance bevacizumab. There was also, just recently, a study that was published, G0G213, about adding back bevacizumab not only improve disease control but also help improve overall survival, and we discussed that a little bit. And I think it’s about a 5- to 6-month improvement in overall survival. So, in your situation, we’re like, “Yes, we think you’re going to respond to these drugs again because you did so well the first time around. We’re going to add the bevacizumab in again because you really did quite well with that and didn’t have a lot of side effects.”

Michelle Berke: No, I really didn’t. It was a nice time, for me, on treatment then.

Angeles Alvarez Secord, MD: And the other thing, too, that I talked to you about is, well, if you’re going to start chemotherapy again, there are 3 different backbones you can use. And I don’t know if you remember this conversation.

Michelle Berke: A little bit, yes.

Angeles Alvarez Secord, MD: It’s paclitaxel/carboplatin/gemcitabine, carboplatinum and liposome, and doxorubicin and carboplatinum. They’re all given on difference sequencing schedules, or different administration schedules, and they have different side effects. And so, that’s another area where that’s really important to have that conversation with the physician who’s taking care of you because the treatment decision that you ultimately go with really depends on patient characteristics and side effects from their past treatment. You had not had too many side effects on the prior treatment.

Michelle Berke: No. I had abdominal cramping and some nauseous moments.

Angeles Alvarez Secord, MD: What about peripheral neuropathy? Because that’s a big one for a lot of people. That’s a numbness and tingling in your finger and toes.

Michelle Berke: A little bit in my feet, but no. And, of course, I’m still dealing with the bloat and the fatigue. The fatigue is another big thing that I’m dealing with right now from treatments.And chemo brain. Fuzzy brain, yes.

Michelle Berke: I didn’t think it was, but I’m experiencing this. I don’t know if it’s old age or if it’s chemo brain, but I think it’s probably a combination of both.

Angeles Alvarez Secord, MD: It’s a combination of both. I think you’re absolutely right. But I think that the chemotherapy certainly accelerates the process, and they’ve done studies now where there’s objective findings showing that, in terms of having people do these scoring tests and seeing that, yes, your brain doesn’t look as well after chemotherapy. So, you’re not alone, and everything you’re feeling is real.

Michelle Berke: Good, that makes me feel better.

Angeles Alvarez Secord, MD: But one of the things I wanted to get back to is peripheral neuropathy. So you were lucky you didn’t have that horribly. About 20% of patients will have this residual peripheral neuropathy. That can be really problematic. In some patients, it can be really severe where it affects their ability to walk or button up their clothing, or do things that they love to do, especially if they’re interested in art work or crochet.

Michelle Berke: I could see that.

Angeles Alvarez Secord, MD: So, if someone is experiencing the peripheral neuropathy, they definitely need to tell their doctor. Because you can do things like a dose reduction or hold therapy until their symptoms improve. Or, treat with a different drug if it’s that bad. There’s even some vitamin therapy that you can choose to do, too.

Michelle Berke: B12?

Angeles Alvarez Secord, MD: B12 is one of them.

Michelle Berke: Yes, I’ve heard that.

Angeles Alvarez Secord, MD: And I haven’t talked to you, but I found this new vitamin cocktail. I was at a meeting and one of the nurses there talked about her patient who had started herself on this vitamin cocktail and it really helped with the peripheral neuropathy.

Michelle Berke: Oh, good.

Angeles Alvarez Secord, MD: My patients who are struggling with that, I give them this. It’s like 5 different vitamins. And then there’s this other thing called Scrambler Therapy that’s done at some centers. I believe it’s still experimental, but some of my patients have had this done, and I think it basically involves the TENS unit. But there’s really a strong need for innovative ideas to try to prevent peripheral neuropathy. But in your situation, it wasn’t problematic so we went back to treating with the paclitaxel and carboplatinum and bevacizumab. And you did well in terms of getting a partial response.

Michelle Berke: I think so, I think it was working for quite a few months.

Angeles Alvarez Secord, MD: Right. And then we did the maintenance bevacizumab for quite some time, too.

Transcript Edited for Clarity

Transcript:

Angeles Alvarez Secord, MD: Michelle, you did great for a while. Things were looking really wonderful. I saw you for a few surveillance visits, and I felt like you were getting your energy back, which was good. Then a year later, it’s 2015, and you had a documented recurrence based on imaging, and your CA-125 started to creep up. At that point, we had a conversation about what the next steps are. But I think we had also discussed before, when you completed treatment, the high recurrence risk. Patients with ovarian cancer, their relapse rate is about 70%.

Michelle Berke: That’s pretty high.

Angeles Alvarez Secord, MD: And I always have a hard time, at the end of treatment that first time, having that discussion because you want to be really honest about the high relapse rate, but you also want to instill hope…

Michelle Berke: And encouragement.

Angeles Alvarez Secord, MD: Right. How did you feel at that moment?

Michelle Berke: Devastating. It’s devastating when you hear that your cancer is back. But there’s no cure for it, so it’s to be suspected. So soon? No, I wasn’t expecting it to come back so soon.

Michelle Berke: Yes. You explained that to me how when you have the BRCA1-positive protein, it actually helps your cancer.

Angeles Alvarez Secord, MD: It does help your cancer. And it doesn’t make sense. That’s the huge paradox, right?

Michelle Berke: Yes.

Angeles Alvarez Secord, MD: It increases the risk of someone having cancer, but at the same time, it makes the cancer more susceptible to the chemotherapy, and that goes into the science about what BRCA1 and BRCA2 proteins do. They’re involved in DNA repair. They’re involved in a specific type of DNA repair that’s the most efficient one. And there are all these different pathways to repair DNA.

Michelle Berke: Fascinating.

Angeles Alvarez Secord, MD: Yes, it is very fascinating. But on the whole, it totally makes sense that it doesn’t make sense.

Michelle Berke: To you, it makes sense. To me, it doesn’t make sense. But I trust you anyway, so I’ll trust you on that.

Angeles Alvarez Secord, MD: Right. It’s a really weird phenomenon. So, at the time that you had recurrence, we talked about different treatment options then. I don’t know if you remember.

Michelle Berke: I do. There were a couple clinical trials.

Angeles Alvarez Secord, MD: We’re really fortunate at our practice that we have so many clinical trials that we can offer patients. In your situation, we chose to do the treatment off of a clinical trial, and we talked about different chemotherapy options and adding back in the bevacizumab.

At that point, there had been some information about bevacizumab improving disease control if you added it back with the chemotherapy. You did what’s called maintenance bevacizumab. There was also, just recently, a study that was published, G0G213, about adding back bevacizumab not only improve disease control but also help improve overall survival, and we discussed that a little bit. And I think it’s about a 5- to 6-month improvement in overall survival. So, in your situation, we’re like, “Yes, we think you’re going to respond to these drugs again because you did so well the first time around. We’re going to add the bevacizumab in again because you really did quite well with that and didn’t have a lot of side effects.”

Michelle Berke: No, I really didn’t. It was a nice time, for me, on treatment then.

Angeles Alvarez Secord, MD: And the other thing, too, that I talked to you about is, well, if you’re going to start chemotherapy again, there are 3 different backbones you can use. And I don’t know if you remember this conversation.

Michelle Berke: A little bit, yes.

Angeles Alvarez Secord, MD: It’s paclitaxel/carboplatin/gemcitabine, carboplatinum and liposome, and doxorubicin and carboplatinum. They’re all given on difference sequencing schedules, or different administration schedules, and they have different side effects. And so, that’s another area where that’s really important to have that conversation with the physician who’s taking care of you because the treatment decision that you ultimately go with really depends on patient characteristics and side effects from their past treatment. You had not had too many side effects on the prior treatment.

Michelle Berke: No. I had abdominal cramping and some nauseous moments.

Angeles Alvarez Secord, MD: What about peripheral neuropathy? Because that’s a big one for a lot of people. That’s a numbness and tingling in your finger and toes.

Michelle Berke: A little bit in my feet, but no. And, of course, I’m still dealing with the bloat and the fatigue. The fatigue is another big thing that I’m dealing with right now from treatments.And chemo brain. Fuzzy brain, yes.

Michelle Berke: I didn’t think it was, but I’m experiencing this. I don’t know if it’s old age or if it’s chemo brain, but I think it’s probably a combination of both.

Angeles Alvarez Secord, MD: It’s a combination of both. I think you’re absolutely right. But I think that the chemotherapy certainly accelerates the process, and they’ve done studies now where there’s objective findings showing that, in terms of having people do these scoring tests and seeing that, yes, your brain doesn’t look as well after chemotherapy. So, you’re not alone, and everything you’re feeling is real.

Michelle Berke: Good, that makes me feel better.

Angeles Alvarez Secord, MD: But one of the things I wanted to get back to is peripheral neuropathy. So you were lucky you didn’t have that horribly. About 20% of patients will have this residual peripheral neuropathy. That can be really problematic. In some patients, it can be really severe where it affects their ability to walk or button up their clothing, or do things that they love to do, especially if they’re interested in art work or crochet.

Michelle Berke: I could see that.

Angeles Alvarez Secord, MD: So, if someone is experiencing the peripheral neuropathy, they definitely need to tell their doctor. Because you can do things like a dose reduction or hold therapy until their symptoms improve. Or, treat with a different drug if it’s that bad. There’s even some vitamin therapy that you can choose to do, too.

Michelle Berke: B12?

Angeles Alvarez Secord, MD: B12 is one of them.

Michelle Berke: Yes, I’ve heard that.

Angeles Alvarez Secord, MD: And I haven’t talked to you, but I found this new vitamin cocktail. I was at a meeting and one of the nurses there talked about her patient who had started herself on this vitamin cocktail and it really helped with the peripheral neuropathy.

Michelle Berke: Oh, good.

Angeles Alvarez Secord, MD: My patients who are struggling with that, I give them this. It’s like 5 different vitamins. And then there’s this other thing called Scrambler Therapy that’s done at some centers. I believe it’s still experimental, but some of my patients have had this done, and I think it basically involves the TENS unit. But there’s really a strong need for innovative ideas to try to prevent peripheral neuropathy. But in your situation, it wasn’t problematic so we went back to treating with the paclitaxel and carboplatinum and bevacizumab. And you did well in terms of getting a partial response.

Michelle Berke: I think so, I think it was working for quite a few months.

Angeles Alvarez Secord, MD: Right. And then we did the maintenance bevacizumab for quite some time, too.